=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295395911
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEXOMA PHYSICIANS GROUP, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2019
-----------------------------------------------------
Last Update Date | 11/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 220 E EVERGREEN ST
-----------------------------------------------------
City | SHERMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75090-5056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-202-2900
-----------------------------------------------------
Fax | 903-202-2901
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 837
-----------------------------------------------------
City | HOWE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75459-0837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOSEPH LIPSCOMB
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 903-202-2900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------